<!DOCTYPE html>
<html>
<head>
    <meta charset="UTF-8">
    <title>极目云医工作平台</title>
    <link rel="stylesheet" type="text/css" href="/static/easyui/css/bootstrap/easyui.css">
    <script type="text/javascript" src="/static/jquery/jquery-1.11.3.min.js"></script>
    <script type="text/javascript" src="/static/js/head.js"></script>
    <script type="text/javascript" src="/static/js/formSubmit.js"></script>
    <!--<link rel="stylesheet" type="text/css" href="/static/css/index.css">-->
    <script type="text/javascript" src="../patient/js/patient.js"></script>
    <script type="text/javascript" src="/static/data/data_dict_sex.js"></script>
    <script type="text/javascript" src="/static/data/data_identity_dict.js"></script>
    <script type="text/javascript" src="/static/data/data_nation.js"></script>
    <script type="text/javascript" src="/static/data/data_marriage_dict.js"></script>
    <script type="text/javascript" src="/static/data/data_relationship.js"></script>
    <script type="text/javascript" src="/static/data/data_dict_charge_type.js"></script>
    <script type="text/javascript" src="/static/data/data_profession.js"></script>
</head>

<body>

<div class="inp-form" style="width: 95%">
    <form id="xinxiForm" method="post">
        <input type="hidden" name="id">
 <!--       <input type="hidden" name="patientId">
        <input type="hidden" name="visitId">
        <input type="hidden" name="hospId">-->
        <table cellpadding="0" cellspacing="0" width="100%" class="apply-tab">
            <tr>
                <td colspan="3">
                    健康卡号   <input name="healthyCardNo" style="width: 100px;" class="easyui-validatebox">
                    &nbsp; 住 院 号  <input name="inpNo" style="width: 199px;" class="easyui-validatebox">
                   &nbsp;&nbsp;姓&nbsp;&nbsp;名 <input name="name" class="easyui-validatebox validatebox-text-xs" required="true">
                   <!-- &nbsp;&nbsp;&nbsp; 姓&nbsp;&nbsp;名 <input name="name" class="easyui-validatebox validatebox-text-xs" required="true">-->
                </td>
            </tr>
            <tr>
                <td colspan="3">
                    性&nbsp;&nbsp;别  <input name="sex" class="easyui-validatebox validatebox-text" style="width:100px;" id="setId">
                    &nbsp; 出生日期  <input  name="dateOfBirth" style="width: 199px;" class="easyui-datebox datebox-f combo-f textbox-f validatebox-text-s">
                    &nbsp;&nbsp;身份证号  <input  name="idNo" class="easyui-validatebox validatebox-text  "   style="width:200px;" validType="idcard">
                    <!--&nbsp;&nbsp;&nbsp; 身份证号 <input  name="name" style="width: 200px;" class="easyui-validatebox validatebox-text" required="true">-->
                </td>
            </tr>
            <tr>
                <td colspan="3">
                    国&nbsp;&nbsp;籍  <input name="citizenship" class="easyui-validatebox validatebox-text" id="citizenship" style="width: 100px;">
                    &nbsp; 民&nbsp;&nbsp;族  <input  name="nation" class="easyui-validatebox validatebox-text "  id="nation" style="width: 200px;">
                    &nbsp;&nbsp;  职&nbsp;&nbsp;业  <input  name="occupation" class="easyui-validatebox validatebox-text validatebox-text-xs"  id="occupation" style="width: 100px;">
                    &nbsp;&nbsp;&nbsp;身&nbsp;&nbsp;份  <input name="identity" class="easyui-validatebox validatebox-text validatebox-text-xs" id="identity" style="width: 200px;">
                </td>
            </tr>
            <tr>
                <td colspan="3">
                    出 生 地  <input name="birthPlace" class="easyui-validatebox validatebox-text" style="width:300px;">
                    &nbsp;&nbsp;
                     籍&nbsp;&nbsp;贯  <input name="nativePlace" class="easyui-validatebox validatebox-text"  style="width: 100px;">
                    &nbsp;&nbsp;  费&nbsp;&nbsp;别： <input  name="chargeType" class="easyui-validatebox validatebox-text " required="true" id="chargeTypeId" style="width: 100px;">
                    &nbsp;&nbsp;&nbsp;婚姻状况： <input name="maritalStatus" class="easyui-validatebox validatebox-text validatebox-text-xs" id="maritalStatus">
                </td>
            </tr>
            <tr>
                <td colspan="3">
                    现 住 址  <input name="patientArea" class="easyui-validatebox validatebox-text" style="width:400px;">
                    &nbsp;
                    &nbsp;&nbsp;电&nbsp;&nbsp;话： <input name="patPhone" class="easyui-validatebox validatebox-text "  data-options="validType:'phone'" style="width:200px;">
                    邮&nbsp;&nbsp;编： <input name="patZip" style="width: 100px;" class="easyui-validatebox validatebox-text" >
                </td>
                    <!---->

            </tr>
             <tr>
                 <td colspan="3">
                     现住详细地址  <input  name="patientAreaAddress" class="easyui-validatebox validatebox-text"  style="width:800px;">
                 </td>
             </tr>
            <tr>
                <td colspan="3">
                    户口地址  <input name="mailingAddressCode" class="easyui-validatebox validatebox-text">&nbsp;&nbsp;
                    邮&nbsp;&nbsp;编  <input  name="zipCode" style="width: 100px;" class="easyui-validatebox validatebox-text">
                </td>

            </tr>
             <tr>
                 <td colspan="3">
                   户口详细地址  <input  name="mailingAddress" class="easyui-validatebox validatebox-text"  style="width: 800px;">
                 </td>
             </tr>
            <tr>
                <td colspan="3">
                    工作单位及地址  <input  value="无" class="easyui-validatebox validatebox-text" style="width:400px;">
                    电&nbsp;&nbsp;话  <input name="phoneNumberBusiness" class="easyui-validatebox validatebox-text " style="width:200px;">
                    邮&nbsp;&nbsp;编  <input  name="businessZipCode"  class="easyui-validatebox validatebox-text"  style="width:100px;">
                </td>
            </tr>
            <tr>
                <td colspan="3">
                    联系人名  <input name="nextOfKin" class="easyui-validatebox validatebox-text validatebox-text-xs" >&nbsp;&nbsp;
                    关&nbsp;&nbsp;系  <input name="relationship" class="easyui-validatebox validatebox-text validatebox-text-xs" id="relationship">&nbsp;&nbsp;
                    电&nbsp;&nbsp;话  <input name="nextOfKinPhone" style="width: 25%;" class="easyui-validatebox" data-options="validType:'phone'" >

                </td>
            </tr>
            <tr>
                <td colspan="3">
                    联系人地址  <input name="nextOfKinAddr" class="easyui-validatebox validatebox-text" style="width:800px;">
                </td>
            </tr>
        </table>
    </form>
    <div class="col-xs-12 text-center">
        <input type="button" value="保存" class="eeasyui-linkbutton l-btn " id="savePat" data-options="iconCls:'icon-save'" style="width:90px" onclick="savePatInfo();">
    </div>
</div>
</body>
